TCRN REVIEW - HEAD AND NECK (NEUROLOGICAL TRAUMA AND MAXILLOFACIAL AND NECK TRAUMA) (29 QU, Exams of Nursing

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TCRN REVIEW - HEAD AND NECK (NEUROLOGICAL TRAUMA AND MAXILLOFACIAL AND NECK TRAUMA) (29 QUESTIONS ON EXAM) 2024 What are the three main constituents in the brain? - ANSWER ☑☑CSF, Brain Tissue (mostly water), Blood The brain makes up approximately _____% of the volume of the skull and is _____% water. - ANSWER ☑☑80% 75% CSF makes up about _____% of the volume of the skull. - ANSWER ☑☑10% There is approximately _____ mL of CSF. - ANSWER ☑☑125-150 mL Blood makes up about _____% of the volume of the skull and _____% of the blood is venous. - ANSWER ☑☑10% 80% The pressure of water, CSF and blood against the skull is known as _____. - ANSWER ☑☑ICP - Intracranial pressure What are the normal ICPs for children and adults? - ANSWER ☑☑Child - 0-5 mmHg Adult - 5-12 mmHg ICP pressures above _____ mmHg in any age group is considered elevated. - ANSWER ☑☑20 mmHg ICP pressures above 20 mmHg do what? - ANSWER ☑☑Compromise blood flow into the skull and contribute to cerebral hypoxia and hypoglycemia. What can happen if ICP pressures climb too high? - ANSWER ☑☑The brain may be forced out of the skull through any opening (such as skull fractures, tentorial plate or foramen magnum). ICP above _____ mmHg is severe and life-threatening. - ANSWER ☑☑40 mmHg ICP between _____ and _____ mmHg is termed "moderate intracranial hypertension". - ANSWER ☑☑20 and 40 mmHg ICP above 20 mmHg is abnormally high and is known as _____. - ANSWER ☑☑Early increased ICP What should resting ICP be? - ANSWER ☑☑Less than 10 mmHg When ICP increases, pressure is exerted downwards on brain tissue, affecting the cerebral cortices _____ and _____. - ANSWER ☑☑Reticular Activating System (RAS) and Cranial Nerves List 6 things caused by pressure on the RAS (Reticular Activating System). - ANSWER ☑☑1. Progressive restlessness 2. Confusion 3. Disorientation 4. Lethargy or combativeness 5. Changes in speech 6. Loss of judgement List 4 motor functions caused by increased ICP. - ANSWER ☑☑1. Monoplegia 2. Hemiplegia 3. Over-pronation or supination of the wrists 4. Pronator drift List 5 eye changes caused by increased ICP. - ANSWER ☑☑Diplopia Hemorrhage (2-10% of patients) What are the risk factors for infection related to ICP monitoring? - ANSWER ☑☑Concurrent systemic infections Longer duration of monitoring (highest risk factor after 10 days of use) Presence of intraventricular hemorrhage or subarachnoid hemorrhage Open skull fracture Trauma Cerebrospinal fluid leakage at the site What are the signs of infection associated with ICP monitoring? - ANSWER ☑☑Headache (if patient has headache from the injury, look for changes in the headache) Neck stiffness Fever AMS New-onset seizures Which patients are most likely to have hemorrhage related to ICP monitoring? - ANSWER ☑☑More likely in patients who develop coagulopathies Discuss hemorrhages related to ICP monitoring? - ANSWER ☑☑Most hemorrhages are small (less than 15 mL) and clinically insignificant. Clinically significant hemorrhage occurs in 1% of cases. What two things are perfusion to cerebral tissue dependent upon? - ANSWER ☑☑An adequate MAP that is able to propel blood from the body into the skull A normal ICP Describe the relationship between MAP and ICP. - ANSWER ☑☑ICP acts against MAP to reduce blood flow from the body into the skull. How do you determine CPP? - ANSWER ☑☑CPP = MAP-ICP What is the average CPP (cerebral perfusion pressure)? - ANSWER ☑☑80-100 mmHg A CPP above _____ mmHg is ideal. - ANSWER ☑☑70 A CPP above _____ mmHg is required for consciousness. - ANSWER ☑☑60 A CPP less than _____ mmHg causes critical reduction in brain tissue oxygenation. - ANSWER ☑☑50 A CPP below _____ mmHg reduces cerebral blood flow to 25% of normal - ANSWER ☑☑40 A CPP below _____ mmHg equates to irreversible brain ischemia - ANSWER ☑☑30 If the MAP is lower than the CPP, the patient is _____. - ANSWER ☑☑Dead What is the first step in performing a neurological assessment? - ANSWER ☑☑Determine LOC What is the LOC of a patient who responds immediately to minimal external stimuli? - ANSWER ☑☑Alert What is the LOC of a patient in a state of drowsiness or inactivity, in which the patient needs increased stimulus to be awakened, but is still easily arousable. - ANSWER ☑☑Lethargic What is the LOC of a patient who is very drowsy when not stimulated, follows simple commands when stimulated, a duller indifference to external stimuli still exists, and response is minimally obtained? - ANSWER ☑☑Obtunded What is the LOC of a patient who has minimal spontaneous movement, arousable only with vigorous and continuous external stimuli, motor responses to tactile stimuli are appropriate, verbal responses are minimal and incomprehensible? - ANSWER ☑☑Stupurous What is the LOC of a patient in which vigorous stimulation fails to produce any voluntary neural response; both arousal and awareness are absent, no verbal responses, motor responses may be purposeful withdrawal to pain in light coma, non-purposeful or absent movement in deep coma? - ANSWER ☑☑Comatose If the patient is awake enough to respond, determine the patient's degree of orientation based off of which 4 questions? - ANSWER ☑☑What happened to you? (Event) What month and year is it? (Time) Can you tell me your home address? (Place) What is your name? (Person) What are usually the first signs of neurological deterioration? - ANSWER ☑☑Changes in orientation Changes of orientation tend to occur in order. What is the order? - ANSWER ☑☑The first sphere of orientation to decline is event, then time, then place. Person is almost always the last sphere to be lost. If the patient has deteriorated to the point where they cannot cooperate with determination of orientation, assess for arousal looking for what signs? - ANSWER ☑☑Spontaneous eye opening Verbalization attempts Moaning Tossing Reaching Leg crossing Yawning Coughing Swallowing What do you do if there are no signs of arousal? - ANSWER ☑☑Call the patient's name loudly watching for a response What do you do if the patient does not respond to the calling of his name? - ANSWER ☑☑gently shake him or her With _____, one pupil tends to become fixed and dilated. - ANSWER ☑☑Unilateral herniation With _____, both pupils tend to become fixed and dilated. - ANSWER ☑☑Bilateral herniation What is the 4th step in a neurological assessment? - ANSWER ☑☑Assess Vital Signs What is a eupnea respiratory pattern? - ANSWER ☑☑moderately fast symmetrical breaths What is Cheyne-Stokes breathing? - ANSWER ☑☑quick deep breaths with intermittent pauses What is central neurogenic hyperventilation? - ANSWER ☑☑Very Rapid deep breaths What is Apneusis - ANSWER ☑☑Virtually apneic breathing What is ataxic breathing? - ANSWER ☑☑Very abnormal breathing with no specific pattern Discuss blood pressure in relation to the neurological assessment - ANSWER ☑☑Hypotension is rare but detrimental Pulse pressure widens Pulse: bradycardia often develops, followed by dysrhythmias What are the BP and HR when the ICP is 10mmHg or less? - ANSWER ☑☑BP is normal Pulse pressure is normal Pulse rate and rhythm is normal What are the BP, Pulse Pressure and Pulse when the ICP is 20 mmHg? - ANSWER ☑☑BP, Pulse Pressure, Rate and Rhythm are all normal. Describe the BP and Pulse when the ICP is 30 mmHg. - ANSWER ☑☑Widening pulse pressure Bradycardia palpated as a full and bounding pulse Describe the BP and Pulse with herniation. - ANSWER ☑☑Wide pulse pressure Bradycardia with irregularities Mild temperature _____ are common with increased ICP - ANSWER ☑☑elevations Temperature elevations due to brainstem lesions will lack _____. - ANSWER ☑☑Sweating and Gooseflesh Rule out _____ rather than assuming temperature elevations are related to increases in ICP. - ANSWER ☑☑infection Describe best eye opening in a Glasgow Coma Score. - ANSWER ☑☑Spontaneous = 4 To verbal command = 3 To pain = 2 No response = 1 Describe best motor response in a GCS. - ANSWER ☑☑Obeys commands = 6 Localizes pain = 5 Withdraws from pain = 4 Abnormal flexion = 3 Abnormal extension = 2 No response = 1 Describe best verbal response in a GCS. - ANSWER ☑☑Oriented = 5 Confused = 4 Inappropriate words = 3 Incomprehensible sounds = 2 No response = 1 A GCS of 13-15 indicates _____. - ANSWER ☑☑Normal function, or a mild brain injury A GCS of 9-12 indicates _____. - ANSWER ☑☑A moderate brain injury A GCS of 3-8 indicates _____. - ANSWER ☑☑Profound brain injury The goal of neurological treatment is to _____. - ANSWER ☑☑Reduce the volume of the skull constituents in order to reduce the ICP. (reducing the volume of the brain) How quickly does Mannitol lower ICP? - ANSWER ☑☑Within 1-5 minutes. What is the peak effect of Mannitol? - ANSWER ☑☑20-60 minutes How long does Mannitol last? - ANSWER ☑☑1.5-6 hours How is Mannitol given? - ANSWER ☑☑As a bolus of 0.25g to 1g/kg (0.25g-0.5g/kg for long term reduction, 1 g/kg for urgent reduction) Is Mannitol preferred as a bolus or as a continuous infusion? - ANSWER ☑☑bolus What should be done with mannitol in order to prevent rebound cerebral edema? - ANSWER ☑☑Tapered down Mannitol should be tapered down in order to prevent _____. - ANSWER ☑☑Rebound cerebral edema What are the advantages of Mannitol? - ANSWER ☑☑Rapid reduction in ICP Expands plasma volume, causing a reduction in hematocrit and blood viscosity Administer a sedative/hypnotic agent and a rapid-acting neuro-blocking agent Titrate mechanical ventilation to establish a pCO2 of between 30-49 mmHg. End tidal capnography is strongly recommended. Suctioning can _____ ICP. - ANSWER ☑☑Increase Discuss ways to manage suctioning in ICP. - ANSWER ☑☑Consider medicating with lidocaine, opiates, or neuromuscular blocking agents prior to suctioning. Hyperoxygenate prior to suctioning Limit suctioning to two passes of the suction catheter, not to exceed 10-15 seconds duration per pass. What are some ways to ensure adequate oxygenation? - ANSWER ☑☑Maintain adequate hemoglobin Ensure adequate arterial PO2 How can you maintain adequate hemoglobin? - ANSWER ☑☑Ensure Hgb is at least 10 g/dL (may require transfusions) How could a Hgb too high be bad related to ICP? - ANSWER ☑☑A Hgb too high is bad because increased blood viscosity can reduce tissue oxygenation How do you ensure adequate arterial PO2? - ANSWER ☑☑Increased FiO2 on the ventilator Cautious use of PEEP (positive-end-expiratory-pressure) List 6 ways to reduce cerebral metabolism. - ANSWER ☑☑1. Maintain a darkened, quiet room 2. Limit visitors appropriately 3. Speak softly 4. Cluster nursing activities 5. Limit dialogue, keep topics light-hearted 6. Regular sedation/analgesia Describe the effect of Diazepam, Lorazepam and Midazolam on BP, ICP and CBP. - ANSWER ☑☑BP decreases No effect on ICP CBP decreases Describe the effect of Morphine, Fentanyl, Alfentanil and Sufentanil on BP, ICP and CBF. - ANSWER ☑☑BP decreases ICP increases No effect on CBF Describe the effect of Propofol and Etomidate on BP, ICP and CBF. - ANSWER ☑☑BP decreases ICP decreases CBF decreases Describe glycemic maintenance to decrease ICF. - ANSWER ☑☑Serum glucose should be maintained between 80-120 using titrated insulin drips. Avoid IV fluids and medications mixed with D5W Seizures are more likely in patients with: (5) - ANSWER ☑☑GCS less than 10 Depressed skull fracture Subdural hematoma Epidural hematoma Intracranial hematoma Prophylactic _____ may prevent early-onset seizures but will have little effect on late-onset seizures. - ANSWER ☑☑Dilantin What is the difference in early-onset seizures and late-onset seizures? - ANSWER ☑☑Early onset seizures are within 7 days of injury Late onset seizures are more than 7 days after the injury What is the loading dose of prophylactic Dilantin? - ANSWER ☑☑20 mg/kg How fast is dilantin administered? Why? - ANSWER ☑☑No faster than 50 mg/minute Faster administration may result in hypotension and circulatory collapse Dilantin can only be mixed with _____. - ANSWER ☑☑Normal Saline What is the preferred route of dilantin? - ANSWER ☑☑Central line Plasma levels should be maintained between _____&_____ while giving dilantin. - ANSWER ☑☑40-80 umol/L When administering dilantin, you should monitor closely for _____. - ANSWER ☑☑Rashes Rashes during administration of dilantin may indicate _____. - ANSWER ☑☑Steven Johnson Syndrome How is normothermia maintained in relation to ICP? - ANSWER ☑☑Treat fevers with antipyretics Sponge baths Cooling blankets Avoid shivering In regard to normothermia, consider _____. - ANSWER ☑☑Indomethecin How is indomethecin beneficial? - ANSWER ☑☑Reduces temperature, CBF and ICP Vasoconstricts blood vessels Which skull bones are the strongest? - ANSWER ☑☑Frontal & Occipital List the 3 meninges from the brain outwards. - ANSWER ☑☑1. Pia 2. Arachnoid 3. Dura What is the term for bleeding between the skull and the dura, usually associated with a blow to the temporal region, causing disruption of the middle meningeal artery? - ANSWER ☑☑Epidural bleed What is the treatment for an Epidural bleed? - ANSWER ☑☑Evacuation of blood (burr hole or surgery) What are the symptoms of an epidural bleed? - ANSWER ☑☑Unconscious at time of incident Rapid recovery of consciousness with a lucid period; associated with an increasingly severe headache Rapid decline in LOC What is the term for bleeding between the dura and the arachnoid mater that is venus? - ANSWER ☑☑Subdural bleed What is the treatment for a Subdural Bleed? - ANSWER ☑☑Institute measures to reduce ICP Frequently needs surgical intervention Describe the symptoms of a subdural bleed. - ANSWER ☑☑Similar to epidural bleed but have a slower onset of symptoms. Acute bleed - symptoms appear within 48 hours of the injury Subacute bleed - symptoms appear 48 hours to 2 weeks after the injury. Chronic bleed - symptoms appear more than 2 weeks after the injury What is the term for bleeding between the arachnoid and pia mater? - ANSWER ☑☑Subarachnoid Bleed What are the symptoms of a subarachnoid bleed? - ANSWER ☑☑Meningeal irritation (worst headache of life, nuchal rigidity, photophobia_ Decreased LOC Motor deficits Pupillary abnormalities What are the treatments for a subarachnoid bleed? - ANSWER ☑☑Measures to reduce ICP Surgery frequently required Calcium channel blockers to reduce local vasospasms Describe the symptoms of a cerebral contusion/intercerebral hematoma - ANSWER ☑☑Symptoms increase with time, may not be apparent for hours or days. Symptoms are dependent on location of lesion Where are cerebral contusions/intracerebral hematomas most common? - ANSWER ☑☑Frontal and Temporal lobes Cerebral contusions/intracerebral hematomas rarely cause _____ initially. If a patient presents with decreased LOC, consider _____. - ANSWER ☑☑unconsciousness diffuse axonal injury What are the physical symptoms of cerebral contusions / intracerebral hematomas? - ANSWER ☑☑Personality changes Deficits in memory, executive function, behavior, language and motor function What are the specific signs of bleeding in the midbrain? - ANSWER ☑☑Deep coma Midpoint fixed pupils Ophthalmoplegia What are the specific signs of bleeding in the pons? - ANSWER ☑☑Coma Pinpoint pupils Ophthalmoplegia Abnormal extension in response to pain What are the specific symptoms of bleeding in the medulla? - ANSWER ☑☑Bilaterally fixed and dilated pupils Death What is the treatment plan for cerebral contusions / intracerebral hematomas? - ANSWER ☑☑Reduce increased ICP as it occurs What is the term for traumatic microscopic damage to cells in the white matter of the brain? - ANSWER ☑☑Concussion A _____ causes reversible physiologic disturbance of neurological function that occurs at the instant of trauma. - ANSWER ☑☑Concussion Describe a Grade 1 Concussion. - ANSWER ☑☑No LOC Short-lived confusion Post-traumatic amnesia less than 30 minutes Describe a Grade 2 Concussion. - ANSWER ☑☑LOC less than 5 minutes Post-traumatic amnesia greater than 30 minutes Retrograde amnesia 5-10 minutes after impact. Describe a Grade 3 Concussion. - ANSWER ☑☑LOC 5 minutes to 6 hours Post-traumatic amnesia greater than 24 hours Retrograde amnesia Describe a Mild DAI (Diffuse axonal injury) - ANSWER ☑☑Brief LOC with rapid recovery This mechanism of injury occurs with the transmission of forces along the line of the axial skeleton (landing on feet or buttocks after a fall or diving injury). - ANSWER ☑☑Vertical compression / axial loading Describe some complications of a vertical compression / axial loading injury. - ANSWER ☑☑The vertebral body is compressed or shattered (burst) and fragments of bone may imbed in the cord (Anterior Cord Syndrome). Vertebrae may open up and cause severe instability. This mechanism of injury occurs when force applied to spinal axis to distract or pull it (hanging). - ANSWER ☑☑Distraction What is the most common site of a distraction injury? - ANSWER ☑☑Cervical spine A drop of _____ greater than the person's height causes irreversible CNS injury. - ANSWER ☑☑18 inches What is a Jeffersonian Ring Fracture? - ANSWER ☑☑Rare fracture of C1 where the body splits into several parts. Usually leaves the patient neurologically intact, although fracture fragments may migrate causing fatality. A Jeffersonian Ring Fracture is frequently associated with what mechanism of injury? - ANSWER ☑☑Axial loading What is an Atlanto-occipital dislocation? - ANSWER ☑☑Rare avulsion oc C1 body from occipital bone Immediately fatal What is an Odontoid (dens) Fracture? - ANSWER ☑☑Severe vertical compression at C2 May or may not involve the cord May be missed on plain films so consider Window CT, Cervial MRI, Open mouth view What is the term fr bilataral avulsion fracture through the arch of C2 with body of C2 separated from supporting. - ANSWER ☑☑Hangman's Fracture What 2 factors are important to remember about a hangman's fracture? - ANSWER ☑☑May be neurologically intact initially Treated with immobility (halo) and bedrest The posterior spinal cord transmits _____> - ANSWER ☑☑Light touch Proprioception Vibration The Anterior spinal cord transmits _____. - ANSWER ☑☑Motor functions The Lateral cspinal cord transmits _____. - ANSWER ☑☑Pain Temperature Crude Touch _____ nerves cross over low where they enter the spinal cord. - ANSWER ☑☑Lateral nerves Anterior and posterior nerves cross over _____, near the base of the brain. - ANSWER ☑☑Bair Complete cord injury at C4 affects the _____ (innervated muscle) and the patient's response is _____. - ANSWER ☑☑Diaphragm Ventilation Complete cord injury at C5 affects the _____ (innervated muscle) and the shrug shoulders, felx elbows. - ANSWER ☑☑Deltoid, Biceps, Brachioradialis Complete cord injury at C6 affects the _____ and the patient response is to _____. - ANSWER ☑☑Wrist Extensor Extend Wrist Complete cord injury at C7 affects what innervated muscle and elicits what patience response? - ANSWER ☑☑Triceps Shrug shoulders, flex elbows Complete cord injury at C8 affects what innervated muscle and elicits what practice in reponsive. - ANSWER ☑☑Flexor digitoum Complete cord injury at T1 affects what innervated muscle and elicits what practice responsive. What is the patient's repsonse to that phone? - ANSWER ☑☑Hand intrinsic muscles Flex fingers Complete cord injury at T2-L1 are effected by what innervated muscle and what is the apatient's response? _____. - ANSWER ☑☑Intercostals Viral Capacity Complete cord block at T2 are effective byiliopsoas and What is the patients reason for signing in._____. - ANSWER ☑☑Vital Capacity Complete injury at T3 affects what innervated muscle and elicits _____ in response. - ANSWER ☑☑What is the patient response? Quadriceps Complete cord injury at T4 is affected by the tibialis anterior muscle and the patient response was _____. - ANSWER ☑☑Ankle Dorsiflexion Complete core injury at T6 is affected by the _____. and the patient response is _____. - ANSWER ☑☑Extension hallucis longus Ankle eversion Sacrao sparing (maintenance of perineal sensation, rectal sphincter and tone and flexor toe movement. How are anterior cord sensory assessments made? - ANSWER ☑☑Use a needle or the broken end of a wooden stick to test for crude touch. When testing sensation, always start from areas of _____ and move towards areas of _____. - ANSWER ☑☑Decreased sensation Increased sensation Upper cervical injuries may develop _____ which _____. - ANSWER ☑☑Hematomas Impede the airway Cervical spinal injuries cause loss of the ability to _____. - ANSWER ☑☑Cough and clear the airway In cervical injuries, if suctioned, limit pass to _____ seconds in order to _____. - ANSWER ☑☑10 seconds decrease vagal stimulation When intubating patients with cervical spine injuries, do not use succinylcholine without a _____. - ANSWER ☑☑Defasciculating agent In cervical spine injuries, the _____ nerve innervates the diaphragm and will be negatively impacted with injuries between _____ and _____. - ANSWER ☑☑Phrenic C3 and C5 Cervical injuries above C4 cause _____. - ANSWER ☑☑diaphragmatic paralysis and respiratory arrest Cervical spine injuries below C4 _____. - ANSWER ☑☑Diaphragm can support breathing A spinal injury between T1 and T8 results in _____. - ANSWER ☑☑Loss of intercostal innervation (responsible for 35% of respiratory effort) A spinal injury above T7 results in _____. - ANSWER ☑☑Decreased ability to cough/deep breathe A spinal injury above T12 results in _____. - ANSWER ☑☑Loss of abdominal muscles, decreasing forceful expiration and coughing _____ after an injury causes swelling to rise up the spinal column in as little as _____ minutes, causing _____ - ANSWER ☑☑Edema 30-60 minutes Increasing neurological deficits including a potential decline in respiratory function List the circulatory treatments for a patient with a spinal cord injury. - ANSWER ☑☑Monitor and treat neurogenic shock as it occurs Patient may have limited or absent peripheral tone, avoid sudden patient movements. Fluid boluses or vasopressors Remember that hypovolemic shock may be masked and exacerbated by neurogenic shock A spinal lesion above S2/S3/S4 may have _____ and develop _____. Place a catheter. - ANSWER ☑☑Areflexive bladder Autonomic Dysreflexia Why is a gastric tube necessary in a patient with a spinal cord injury? - ANSWER ☑☑High cervical lesions have ileus for the first 24 hours with an increased risk of vomiting. What is the term for a temporary local neurological condition that occurs immediately after the spinal cord injury in which swelling and edema of the cord create the effect of a physiologic trans-section with disruption of nerve conduction? - ANSWER ☑☑Spinal Shock What are the symptoms of spinal sock? - ANSWER ☑☑Severe pain just above the injury Flaccid paralysis and absent reflexes Lack of sensory function Impaired thermoregulation Bowel distension/ileus Describe the outcomes of spinal shock. - ANSWER ☑☑Usually subsides in hours to weeks Anal and bulbocavernous reflex will return Spasticity usually supersedes the flaccid state after several weeks in areas where no function has returned What is the bulbocavernosus reflex? - ANSWER ☑☑When the glans penis or clitoris is squeezed, OR the urinary catheter is tugged on, anal sphincter contraction is noted What are common injuries associated with neck injuries? - ANSWER ☑☑Pneumothorax Hemothorax Spinal Cord Injuries List the symptoms of trauma to airway structures. (8) - ANSWER ☑☑Dyspnea, tachypnea Hoarseness, dysphonia Dysphagia Hemoptysis Subcutaneous emphysema Decreased or absent breath sounds Continuous bubbling in a patent chest drainage system Signs of airway obstruction What are the symptoms of trauma to the blood vessels of the neck? - ANSWER ☑☑Hemoptysis Bruits Obvious external bleeding or expanding hematoma Neurological deficits (aphasia, loss of extremity movement or sensation) Do not use if patient is less than 48 inches tall (nor in pediatric patients). Discuss a king airway. - ANSWER ☑☑Adult sizes only - greater than 48 inches tall. No pediatric sizes. Two balloons both inflated with single lumen. After insertion, ventilate and withdraw tube until placement is confirmed. What are the advantages of an endotracheal tube? - ANSWER ☑☑Stable airway Provides protection from aspiration Permits mechanical ventilation Decreases gastric distention What are the disadvantages of an endotracheal tube? - ANSWER ☑☑Esophageal or right mainstem bronchus intubation Vocal cord or pharyngeal injury Conversion of non-deficit to deficit spinal cord injury What are the advantages of a cricothyrotomy? - ANSWER ☑☑More rapid, greater ease of accessibility and lower incidence of bleeding than tracheostomy. Contraindicated in children under 12 years of age. May be performed on conscious patient with local anesthesia. What are the risks of a cricothyrotomy? - ANSWER ☑☑Vocal cord injury Aspiration Hemorrhage Tracheal or esophageal laceration What size tube is needed for a cricothyrotomy and how far is it placed? - ANSWER ☑☑Insert a 6.0 ETT 2 cm beyond the cricothyroid membrane to maintain the airway. Discuss a needle cricothyrotomy. - ANSWER ☑☑Ventilate with a jet insufflator If jet insufflator is not available, put a 3.0 ETT adaptor over the needle and use the BVM to oxygenate. Will not allow appropriate release of CO2 and causes hypercarbia Discuss a tracheostomy. - ANSWER ☑☑Surgical technique with less blood loss than a cricothyrotomy. Bypasses upper airway and glottis, stable airway with low resistance to air flow, easily suctioned. Takes time to perform, used for long term airway control. _____ is frequently associated with spinal cord injuries. - ANSWER ☑☑Maxillofacial trauma _____ is the most common site of spinal cord injury with maxillofacial trauma. - ANSWER ☑☑C2 Describe closure times for facial lacerations. - ANSWER ☑☑Ideally closed within 2 hours After 6 hours, bacterial invasion is usually significant Describe the important things to remember with lip lacerations and with cheek lacerations. - ANSWER ☑☑Lips - maintain vermillion border for cosmetic reasons Cheek - Look for bloody discharge in the mouth or saliva in the wound, which could indicate separation of Stensen's duct. What should you remember about tongue lacerations? - ANSWER ☑☑Typically heal well Teach good mouth care to prevent infection What should you remember about ear lacerations? - ANSWER ☑☑Poor viability due to limited vascularity and cartilage construction What should you remember about eyebrow lacerations? - ANSWER ☑☑Do not shave What should you remember about eyelid lacerations? - ANSWER ☑☑Laceration to medial 1/3 poses a risk for disruption of lacrimal apparatus - require plastic surgery or opthalmology for closure. What is the strongest facial bone? - ANSWER ☑☑Mandible What is the third most commonly injured bone? - ANSWER ☑☑Mandible 50% of mandibular fractures are _____ or _____. - ANSWER ☑☑Multiple or Bilateral When assessing a mandible fracture, always look to _____. - ANSWER ☑☑Exclude a second fracture. What are the symptoms of a mandibular fracture? - ANSWER ☑☑Malocclusion and facial asymmetry are the strongest predictors of mandibular fracture Drooling Malocclusion (teeth do not fit together) Hematoma to the floor of the mouth Dental trauma/avulsed teeth Bleeding around the teeth adjacent to the fracture Anesthesia to the lower lip/chin What are the two strongest indicators of a mandibular fracture? - ANSWER ☑☑Malocclusion Facial assymetry What is an Ellis I Fracture? - ANSWER ☑☑Dental fracture - through the enamel of the teeth (chalky white appearance) What is an Ellis II Fracture? - ANSWER ☑☑Fracture through the enamel and dentin of the teeth (yellowish appearance) What is the treatment for an Ellis I and Ellis II fracture? - ANSWER ☑☑Application of calcium hydroxide to the tooth to reduce likelihood of further injury and exposure to saliva/air which may lead to pulpitis Oral analgesia Dental referral What are the symptoms of zygomatic fractures? - ANSWER ☑☑Orbital floor displacement with limited eye movement. Periorbital ecchymosis Subcutaneous emphysema Difficulty opening and closing the mouth Diplopia / exopthalmos Numb lower lid, medial cheek, upper lid (infraorbital nerve) Flattening of the upper cheek What is the mnemonic to remember with a zygomatic fracture? - ANSWER ☑☑TIDES T - Trismus I - Infraorbital anesthesia D - Diplopia E - Epistaxis S - Lack of symmetry What are the symptoms of an orbital fracture? - ANSWER ☑☑Enopthalmos (eye sinks into the head) Exopthalmos (eye protrudes from the head) Ocular entrapment What are the signs of ocular entrapment? - ANSWER ☑☑Decreased vertical ocular rotary movements Pain on upward gaze Eye cannot look above midline Eye often looks down and out What is important to remember in maxillofacial trauma? - ANSWER ☑☑Allow the patient to assume a position to protect the airway (while protecting C-spine) Describe the airway treatments for patients who present with maxillofacial trauma - ANSWER ☑☑Suction as needed Orogastric tube Jaw-thrust maneuver as required Early consideration of airway control: OPA/NPA Supraglottic airway Endotracheal Intubation Surgical airway What are the important teaching points for injuries involving the sinuses? - ANSWER ☑☑Do not blow your nose Do not perform valsalva maneuver Precautions need to be taken to prevent vomiting What is the name of bleeding in the anterior chamber due to rupture of a vessel in the iris? - ANSWER ☑☑Hyphema What are the 4 types of hyphemas? - ANSWER ☑☑Small Moderate Severe Total (8 ball hyphema) Describe a Small hyphema. - ANSWER ☑☑Blood in 33% or less of anterior chamber Describe a Moderate hyphema. - ANSWER ☑☑Blood in 33-50% of anterior chamber Describe a severe hyphema. - ANSWER ☑☑Blood in more than 50% of anterior chamber Describe a total or 8 ball hyphema - ANSWER ☑☑Entire anterior chamber is filled with blood. What is the chief complaint of a patient who presents with a hyphema? - ANSWER ☑☑Pain and decreased vision, reddish discoloration to vision, moving spots in the eyes A hyphema has _____ which may cause pain, nausea and vomiting. - ANSWER ☑☑Increased intraocular pressure In a hyphema, red blood indicates _____ and brown blood is an _____. - ANSWER ☑☑New Bleed Older Bleed What are the treatments for a hyphema? - ANSWER ☑☑Total bed rest for 3-5 days Sit up 30-45 degrees Metal shield over eye Eye rest (no reading) Sedation Non-aspirin containing analgesia What are the complications of a hyphema? (2) - ANSWER ☑☑Re-Bleed Increased intra-ocular pressure Describe a Re-Bleed associated with a hyphema. - ANSWER ☑☑Causes corneal staining and narrow angle glaucoma Second bleed can be worse and lead to 8-ball hyphema Aminocaproic acid and steroids may reduce the incidence of re-bleeding What is done to decrease intra-ocular pressure? - ANSWER ☑☑Beta-blockers (timolol) Adrenergics Carbonic anhydrase inhibitors (diamox) Avoid mioitics Perforating - Complete disruption of the sclera an cornea (through-and-through) What are the symptoms of penetrating and perforating globe injuries? - ANSWER ☑☑Change in the shape of the pupil (tear drop shaped pupil) Unequal pupils Decreased visual acuity Black/brown defect (caused by choroid/uveal prolapse into the defect) Pain Leakage of vitreous humor Enopthalmos with flat or shallow anterior chamber Hyphema What are the treatments for a penetrating or perforating globe injury? - ANSWER ☑☑DO NOT remove an impaled foreign body DO NOT manipulate the eye DO NOT instill eye drops or apply antibiotic ointments DO NOT measure intraocular pressure Eye shield (should rest on the bone of the brow and the cheek and not exert pressure on the eye) Secure protruding objects with gauze rolls or a paper cup; patch the unaffected eye simultaneously Discourage the patient from bending, stooping, or moving the head suddenly What are the symptoms and treatment of a lens dislocation/subluxation? - ANSWER ☑☑Symptoms: Pain and monocular diplopia Treatment: Opthamology consult What is the term for the iris being torn from the ciliary body? - ANSWER ☑☑Irododialysis What are the symptoms of irododialysis? - ANSWER ☑☑Patient appears to have a second pupil Hyphema Monocular diplopia What are the symptoms of a retinal detachment? - ANSWER ☑☑painless darkening/haziness in the visual field or complaints of curtain or shadow in the visual field photopsia or floaters What is the term for a brilliant flash of light in the visual field? - ANSWER ☑☑Photopsia What is the term for when the entire globe is found outside of the bony orbit? - ANSWER ☑☑Globe luxation What is the treatment for a globe luxation? - ANSWER ☑☑Cover with a cup or a cone Early reduction to minimize traction on the optic nerve List some examples of chemicals that can cause an alkali burn to the eye. - ANSWER ☑☑Ammonia Sodium hydroxide Potassium hydroxide Calcium hydroxide Magnesium hydroxide What are some common sources of alkali burns to the eye? - ANSWER ☑☑Fertilizers Drain cleaners, lye Lime, mortar, cement, whitewash Fireworks, sparklers, flares List some examples of chemicals that can cause an acidic burn to the eye. - ANSWER ☑☑Sulfuric acid Sufurous acid Hydroflouric acid Chromic acid Hydrochloric acid What are some common sources of acidic burns to the eye? - ANSWER ☑☑Battery acid Glass polish Bleach Vinegar What are the symptoms of a chemical burn to the eye? - ANSWER ☑☑Sever pain Diminished / blurred vision Haziness of the cornea Cataract formation Glaucoma What are the treatments for a chemical burn to the eye? - ANSWER ☑☑Remove contact lenses Instill topical anesthetic and/or cycloplegic/mydriatic if severe pain or ciliary spasm Immediate decontamination with neutral fluid aiming stream from inner to outer canthus making sure fornices are flushed Allow eye to equilibrate after each liter of solution for 5-10 minutes before checking pH check pH after each liter of fluid, and discontinue lavage when pH of 7.4-7.6 is achieved. What is the goal pH of the eye after treatment for a chemical burn? - ANSWER ☑☑pH = 7.4-7.6